NCLEX-RN
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1. The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basic tenets of this theory?
- A. The causation of illness is based on supernatural forces that influence the humors of the body.
- B. Herbs and medicines are classified based on their physical characteristics of hot and cold and the humors of the body.
- C. The four humors of the body consist of blood, yellow bile, black bile, and phlegm.
- D. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body.
Correct answer: D
Rationale: The hot/cold theory of health and illness is based on the four humors of the body: blood, phlegm, black bile, and yellow bile. These humors regulate the basic bodily functions, described in terms of temperature, dryness, and moisture. The treatment of disease in this theory involves adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors. Choice A is incorrect as the theory is not based on supernatural forces but on the balance of bodily humors. Choice B is incorrect as herbs and medicines are not classified solely based on their physical characteristics of hot and cold in this theory. Choice C is incorrect as the four humors are blood, phlegm, black bile, and yellow bile, not spiritual connectedness or social aspects. Therefore, the correct choice is D, as it accurately reflects a foundational tenet of the hot/cold theory of health and illness.
2. A patient's blood pressure is 118/82 mm Hg. The patient asks the nurse, "What do the numbers mean?"? Which is the best reply by the nurse?
- A. "The numbers are within the normal range and are nothing to worry about."?
- B. "The bottom number is the diastolic pressure and reflects the pressure in the arteries when the heart relaxes."?
- C. "The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts."?
- D. "The concept of blood pressure can be complex. The primary thing to be concerned about is the top number, or the systolic blood pressure."?
Correct answer: C
Rationale: The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction. The nurse should answer the patient's question in terms they can understand and not just say it is normal and there is nothing to worry about. The diastolic pressure is the pressure in the vessels when the heart is at rest, not the stroke volume. Both the systolic and diastolic blood pressure are important. Choice A is incorrect as providing a vague reassurance does not address the patient's query. Choice B is incorrect as it inaccurately describes the diastolic pressure as reflecting stroke volume, which is incorrect. Choice D is incorrect as it oversimplifies the explanation, focusing solely on the top number without providing a complete understanding of blood pressure.
3. A patient is in the office for a cyst removal and is very anxious about the procedure. Which of the following descriptions of his respirations would be expected?
- A. Bradypnea
- B. Orthopnea
- C. Tachypnea
- D. Dyspnea
Correct answer: C
Rationale: Tachypnea is defined as a rapid, quick, and shallow respiration rate. When a patient is anxious, they may hyperventilate, leading to tachypnea. Bradypnea (Choice A) is slow breathing, which is not expected in an anxious patient. Orthopnea (Choice B) is difficulty breathing while lying down and is not directly related to anxiety. Dyspnea (Choice D) is shortness of breath, which may not be the primary respiratory pattern seen in an anxious patient undergoing a procedure. Therefore, the correct choice is tachypnea as it aligns with the expected respiratory response to anxiety.
4. A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up."? Which nursing intervention should have the highest priority?
- A. Self-esteem-building activities
- B. Anxiety self-control measures
- C. Sleep enhancement activities
- D. Suicide precautions
Correct answer: D
Rationale: The highest priority nursing intervention in this scenario should be suicide precautions. The patient's statement indicates suicidal ideation, which poses an immediate risk to their safety. By implementing suicide precautions, the nurse can ensure constant monitoring and intervention to prevent any self-harm. While addressing self-esteem, anxiety, and sleep issues are essential, ensuring the patient's safety by prioritizing suicide precautions is crucial. Self-esteem-building activities, anxiety self-control measures, and sleep enhancement activities are important interventions but should follow the immediate concern of preventing harm from suicidal thoughts.
5. Which theory reflects the view that illness is caused by an imbalance or disharmony in the forces of nature?
- A. Germ theory
- B. Naturalistic theory
- C. Magicoreligious theory
- D. Biomedical or scientific theory
Correct answer: B
Rationale: The naturalistic theory posits that illness results from an imbalance or disharmony in the forces of nature. According to this theory, maintaining a natural balance or harmony is essential to prevent illness. Conversely, germ theory and biomedical or scientific theory attribute illness to microorganisms, while magicoreligious theory attributes illness to supernatural forces such as deities or spirits. Therefore, the most appropriate theory reflecting the belief that illness arises from a disruption in natural forces is the naturalistic theory.
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